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The Decline of the Physical Exam in Modern Medicine

Ohanian Comment: There's definitely a moral here--for the education deformers who think high powered tests should define kids and their teachers.

Note that this piece, whose subhead reads Doctors today are too uncomfortable with uncertainty, is written by a cardiologist. I know that uncertainty rules the successful classroom.

The author also notes that real role of physical exams in modern medicine is to help doctors decide rationally, not reflexively, when to turn to technology. Think of how this principle applies to what the real role of testing should be in public schools

By Sandeep Jauhar

One morning a few years ago, my older brother phoned me in a panic. Our father had been having episodes of numbness and tingling in his left arm. My brother was worried they were transient ischemic attacks, or ministrokes. He said he was taking my father to the hospital--the one where I work as a cardiologist--to be evaluated.

A neurologist saw my father in the emergency room. Suspecting a mini-stroke, she sent him for a CT scan of the brain, which came up normal. Because early strokes don’t always manifest on a CT scan, she ordered an MRI of his head and brain stem as well, which also revealed nothing unusual. Then she decided to admit him and start him on blood thinners.

The following day, my father got an echocardiogram to see if there was a blood clot in his heart that could have partially dislodged and landed up in his brain. There was not. He also got a transesophageal echo, in which an ultrasound camera was passed via a stiff tube into his mouth, down his throat, and into his esophagus to get close-up views of his heart. It too was unremarkable.

Over the next couple of days, my father underwent a battery of further tests: a carotid ultrasound, a transcranial Doppler, a lower-extremity Doppler, and a chest CT. It seemed a bit excessive to me, but I kept that to myself. The studies all showed normal results.
I think the real role of physical exams in modern medicine is to help doctors decide rationally, not reflexively, when to turn to technology.

After three days of inconclusive tests, my father’s symptoms had abated, and he showed no speech or other neurological deficits. So he was sent home with prescriptions for four medications to prevent strokes and orders to follow up with a neurologist. Three days later, when I was at work, my father's symptoms returned, worse than ever. He now said he had virtually no sensation remaining in his left arm.

Back in the ER, the cycle began all over again. A different neurologist ordered another CT scan. When it revealed nothing new, preparations were made for a repeat MRI.

Then, as my father lay there among shouting drunks and screaming children, appearing about as miserable as I’d ever seen him, a nurse took me aside. "Don't know if I should mention this, Dr. Jauhar," she said, "but I've noticed your father's symptoms get worse when he tilts his head."

She'd had him do certain maneuvers, like touching his chin to his sternum, which reproduced his symptoms exactly. I went over to his stretcher and had him repeat the motions. "That's it," my father said, dipping his chin down unnaturally. "Now I cannot feel my arm."

When I informed the neurologist of the nurse's findings, he walked over to my father and, looking surprised, had him perform the exercises again. Sure enough, the numbness was reproducible, suggesting that my father only had a pinched cervical nerve, a relatively benign condition. Appearing chastened, the neurologist said the MRI was now probably unnecessary but advised my father to have it anyway—now with the range of the images extending into the neck—to eliminate any residual uncertainty. It confirmed what the nurse had suspected: a pinched nerve.

For weeks afterward I fumed over the neurologists’ oversight. If only they had examined my father properly, a $20,000 diagnostic work-up and a great deal of discomfort and worry could have easily been avoided.

But I should hardly have been surprised. In the not-too-distant past, keen observation and the judicious laying on of hands were virtually the only diagnostic tools a doctor had. Today they seem almost obsolete. Technologies like MRIs and CT scans rule the day, permitting diagnosis at a distance. Many doctors don't even carry a stethoscope anymore.

I think back to my own physical diagnosis course in medical school. Our instructor was an intense but likable oncologist who dutifully taught us the mechanics of physical examination and uttered the usual homilies about its importance, but he was clearly ambivalent about its value. In response to a question, he once scoffed that it would take two days to perform the complete physical exam described in our textbook.

Attitudes toward physical diagnosis did not improve during internship and residency. As residents, we were apt to regard the physical exam as an arcane curiosity, like the etiquette lessons of an old aunt you've been told to respect. Who had the time to concentrate on proper examination technique--for example, laying your patient down at an angle of 30 degrees and measuring her jugular pulsations with a ruler--when you had 15 patients to see? Our apathy only seemed to fuel our senior physicians' fear that exam skills in our generation of doctors would atrophy and die.

In fact, evidence suggests that this was already happening. In a 1992 study at Duke University Medical Center, residents in internal medicine were asked to listen to three common heart murmurs programmed into a mannequin. Roughly half could not identify two of the murmurs, despite testing in a quiet room with ample time--hardly normal conditions. About two-thirds missed the third murmur. (Re-testing did not improve performance.) A variety of more recent studies have shown similarly abysmal results.

The main reason for this indifference to physical exams, I've come to believe, is that doctors today are uncomfortable with uncertainty. If a physical exam can diagnose a pinched cervical nerve with only 90 percent probability, then there is an almost irresistible urge to order a thousand-dollar MRI to close the gap. Fear of lawsuits is partly to blame, but the stronger fear, I think, is of subjective observation itself. Doctors are uneasy making educated guesses based on what they see and hear.

There's no point in romanticizing the old days of hands-on medicine. But physical exams do have some clear advantages over more sophisticated technology. They're less expensive. One can use them more easily to make serial observations. And they probably enhance the intimacy that underlies the doctor-patient relationship. A surgeon once told me that he felt obliged to examine his patients for just this reason. "When I listen to their hearts, I make sure to put my hand on their shoulder to convey a sense of warmth,” he said. "I think it is enormously important to touch patients before I cut into them."

But I think the real role of physical exams in modern medicine is to help doctors decide rationally, not reflexively, when to turn to technology. The data from our machines has to be filtered through our eyes and minds. So inevitably, the results of scans and tests get contaminated by the very subjectivity that we are trying to free ourselves of. Doctors cannot escape the need to use their judgment--and it would be best if they exercised it before ordering a $20,000 work-up.

— Sandeep Jauha
Pacific Standard





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